Dorsal pancreatic agenesis

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Dorsal pancreatic agenesis
Suckale08FBS fig1 pancreas development.jpeg
Embryonic development of pancreas. Showing the dorsal rotation and fusion of ventral bud with dorsal bud during the sixth and seventh week of gestation.

Dorsal pancreatic agenesis is a congenital anomaly characterised by the absence of the duct of Santorini, tail and body of the pancreas. [1] It is regarded as asymptomatic and the most common clinical manifestation is non-specific abdominal pain. [2] While the cause is unclear, its mechanism is thought to be impaired dorsal buds or mutation of genes that regulate organogenesis during embryogenesis. [1]

Contents

Early diagnostic methods are laparotomy and autopsy. [1] Endoscopic retrograde cholangiopancreatography (ERCP) and computed tomography scan (CT scan) are combined for diagnosis of this agenesis in recent years. [1] [3] No specific medications are needed for relieving symptoms, but pancreatic enzymes capsule and insulin are prescribed. [4]

Scholars have studied several transcription factors and proteins that can manipulate pancreatic growth and related to dorsal pancreatic agenesis. [5] [6] This malformation is associated with other pancreatic disorders including pancreatitis and pancreatic tumors. [2] [7] Also, patients with this dysgenesis are usually accompanied with pancreatic exocrine dysfunction such as diabetes mellitus.

The prevalence and geographical pattern are unknown. [2] First reported in 1911 by Heiberg in an autopsy. [2]

Signs and symptoms

The agenesis of the dorsal pancreas is asymptomatic in most cases due to the functional reserves of exocrine and endocrine pancreas. [1] [7] Thereby it is often diagnosed incidentally by autopsy, surgery, endoscopy, or imaging technologies during evaluation of other diseases. [3] [7] Some common indicators reported by patients include abdominal pain, weight loss, and jaundice. [7] Abdominal pain could be associated with acute or chronic pancreatitis, pancreatic tumor, diabetic autonomic neuropathy; and weight loss can also be due to diabetes mellitus in some patients. [1] [8]

The localisation of abdominal pain is at epigastrium and aggregates after meals. [8] The two possible reasons for abdominal pain include the underdevelopment of the papillary muscle of the sphincter of Oddi or the autonomic neuropathy due to diabetes mellitus. [1] [8] Dorsal pancreatic agenesis is associated with diabetes mellitus because the β cells in the islets of Langerhans are present in the pancreatic body and tail, which are both absent in agenesis of the dorsal pancreas. Patients with dorsal pancreatic agenesis may result in a defect in the metabolism of hepatic glycogen, which may be related to the reduced β cell mass. [7]

Associated conditions

Pancreatitis

Pancreatitis is a common disorder associated with dorsal pancreatic agenesis. However, it is unclear whether the high occurrence of pancreatitis is due to repetitive imaging procedures or whether it is a comorbidity of agenesis. [7]

Diabetes mellitus

Diabetes mellitus is an endocrine disease that is due to insufficient amount of insulin produced by the pancreas, and it is another common disease linked with dorsal pancreatic agenesis. [3] Insulin is produced by the β cells of the islet of Langerhans in the dorsal pancreas. In patients with agenesis of the dorsal pancreas, the amount of β cells are reduced thus leading to a high possibility of causing diabetes mellitus. [7] [3]

Pancreatic tumors

Tumors can also be associated with dorsal pancreatic agenesis. Reported pancreatic tumors include solid papillary, solid pseudopapillary tumors, adenocarcinomas, and intraductal papillary mucinous neoplasms (IPMN). [1]

Organ malfunction

Organ malfunction is also associated with dorsal pancreatic agenesis. Disorders such as polycystic kidney disease, Kartagener syndrome, multiple splenic deformities, congenital choledochal cysts, and biliary atresia have been reported. [4]

Cause

There is no suggested cause for the dorsal pancreatic agenesis, however there are several hypotheses for the underlying mechanism. [1] [9] As the dorsal pancreatic bud is the ancestor for the majority of pancreas, one possible explanation to this rare anomaly is the dorsal mesentery ischemia which induces the dysgenesis of pancreas. [1] In spite of the unknown molecular mechanism, some scholars have speculated the mode of inheritance of this agenesis, which is autosomal-dominant or X-linked disease. [9] [10]

Genetics

Scientists have demonstrated a wide spectrum of genes that can manipulate and regulate the embryonic pancreatic development by in vivo animal study. The formation of dorsal and ventral buds is reliant on the interaction of transcription factors, for instance the Pax4, Pax6 and Ptf1a. [1] [5] By expressing sonic hedgehog (Shh) or Indian hedgehog (Ihh), the growth of both dorsal and ventral buds from the foregut endoderm is repressed to a large extent, inhibition of Shh or Ihh signaling pathway favor the pancreatic development. [6]  The Homeodomain protein HB9 (Hlxb9) is critical for the formation of the dorsal bud, however it is not significant to the ventral bud. Another homedomain protein, PDX1 (also known as Ipf-1 insulin promoter factor 1) is the initiator of buds expression, genetic mutation on gene Ipf-1 can lead to pancreatic agenesis. [1] [9] Also, both heterozygous and homozygous variant of PDX1 can cause dysgenesis of pancreas and neonatal diabetes. [11]

CDH2 (CD352) gene encoded Neural-cadherin (N-cadherin) is identified to have a active role in recruiting dorsal pancreatic mesenchyme for pancreatic morphogenesis, depletion of N-cadherin in mice can lead to the apoptosis of dorsal pancreatic mesenchyme cells. [12] Moreover, research suggests that retinoid acid is significant for the development of pancreas as the deficiency of retinoid acid can induce dorsal pancreatic agenesis in mice. [13]

Embryonic development of pancreas

The pancreas is responsible for secreting various enzymes for most digestion. It is a retroperitoneal organ posterior to the great curvature of the stomach. Its anterior surface is covered by the parietal peritoneum while the posterior surface contacts the aorta as well as other viscera on the left posterior body wall. Its 15 cm entity is divided into three parts, a globular head attached to the right side of duodenum, a long body, and a blunt head. [14] In embryonic development, the pancreas is formed by the convergence of the two pancreatic buds (dorsal and ventral) during the sixth and seventh week of gestation, but the development of these two buds is initiated at about week 4. [14] During the gestation phase which takes place at week 4, the dorsal bud develops from the dorsal mesentery, and form the body and tail of the pancreas. Meanwhile, the ventral bud arises inferior to form the head of the pancreas. [1] Two weeks later, the ventral bud will rotate dorsally and fuse with the dorsal bud to form the pancreas. The fusion of the duct happened at the same time, to form the duct of Wirsung and the duct of Santorini. [15] Any deviation from the normal pancreatic embryogenesis process can potentially leads to congenital malformation of the pancreas. Among all anomalies, Pancreatic Divisum is the most prevalent one, followed by Pancreatic Heterotopia. [1] [7] In comparison, a complete agenesis of dorsal pancreas is rare and often associated with infant mortality. [1]

The agenesis of dorsal pancreas can be classified into two classes based on the morphological features: complete and partial agenesis. For the former one, the accessory pancreatic duct (also known as duct of Santorini) as well as the body and tail of the pancreas are missing. [1] For partial agenesis, the tail of the pancreas is still present. [1]

Diagnosis

CT scan of the abdomen, showing the presence of pancreas. CT Scan General Illustration Upper Abdomen.jpg
CT scan of the abdomen, showing the presence of pancreas.

Dorsal pancreatic agenesis with advancement in modern day technology, is currently diagnosed with the following imaging technologies, and sometimes a combination of these methods.

Illustration of the endoscopic retrogradecholangiopancreatography (ERCP). Showing a visible pancreas in yellow. Detailed diagram of an endoscopic retrograde cholangio pancreatography (ERCP) CRUK 001.svg
Illustration of the endoscopic retrogradecholangiopancreatography (ERCP). Showing a visible pancreas in yellow.

Agenesis of dorsal pancreas has to be differentiated with pancreatic fat infiltration, chronic pancreatitis and atrophy of pancreatic body and tail. [4] The absence of pancreatic body and tail is the usual manifestation of dorsal pancreatic agenesis, the density and morphological features of the pancreatic head should be either normal or slightly enlarged due to compensation of the absent body and tail. [4]

Stomach/intestine sign can combine with CT for better diagnosis. Since dorsal pancreatic agenesis can be at times complicated with pancreatic tumors, CT is a visualisation tool that can be used to exclude both pancreatic tumors and abdominal tumors, which allows for improved observation. [1]

Management

Vast majority of dorsal pancreatic agenesis cases are diagnosed incidentally and asymptomatic, hence there is no special medication for dorsal pancreatic agenesis. [1] [7] [16]

Medication

1. Pancreatic enteric-coated capsules. A proposed study suggested dorsal pancreatic agenesis patients show Exocrine Pancreatic Insufficiency (EPI) related symptoms. [4] Oral administration of pancreatic enzymes, including lipase, protease and amylase is useful for relieving EPI related symptoms. In addition, pay attention to drugs that may interact with pancreatic enzymes such as Acarbose and Miglitol. [17]

2. Exogenous insulin. Patients with dorsal pancreatic agenesis have lost the tail of pancreas which contain the Islet of Langerhan for insulin production. Therefore, exogenous insulin can be used to treat the accompanied Diabetes Mellitus. [4]

History

Dorsal pancreatic agenesis is an extremely rare disease, there are only about 100 cases reported so far and no association discovered between a specific geographical location and disease prevalence. [2] First reported in 1911 by Heiberg in an autopsy. [2] The patient was diagnosed with diabetes mellitus and associated with pulmonary tuberculosis, the observed morphology of pancreatic head was described as "large and thick". [7] Two years later, the second case was reported by Ghon and Roman (1913). [7]

Related Research Articles

<span class="mw-page-title-main">Pancreas</span> Organ of the digestive system and endocrine system of vertebrates

The pancreas is an organ of the digestive system and endocrine system of vertebrates. In humans, it is located in the abdomen behind the stomach and functions as a gland. The pancreas is a mixed or heterocrine gland, i.e., it has both an endocrine and a digestive exocrine function. 99% of the pancreas is exocrine and 1% is endocrine. As an endocrine gland, it functions mostly to regulate blood sugar levels, secreting the hormones insulin, glucagon, somatostatin and pancreatic polypeptide. As a part of the digestive system, it functions as an exocrine gland secreting pancreatic juice into the duodenum through the pancreatic duct. This juice contains bicarbonate, which neutralizes acid entering the duodenum from the stomach; and digestive enzymes, which break down carbohydrates, proteins and fats in food entering the duodenum from the stomach.

<span class="mw-page-title-main">Pancreatitis</span> Inflammation of the pancreas

Pancreatitis is a condition characterized by inflammation of the pancreas. The pancreas is a large organ behind the stomach that produces digestive enzymes and a number of hormones. There are two main types: acute pancreatitis, and chronic pancreatitis.

<span class="mw-page-title-main">Pancreatic cancer</span> Type of endocrine gland cancer

Pancreatic cancer arises when cells in the pancreas, a glandular organ behind the stomach, begin to multiply out of control and form a mass. These cancerous cells have the ability to invade other parts of the body. A number of types of pancreatic cancer are known.

<span class="mw-page-title-main">Acute pancreatitis</span> Medical condition

Acute pancreatitis (AP) is a sudden inflammation of the pancreas. Causes, in order of frequency, include: a gallstone impacted in the common bile duct beyond the point where the pancreatic duct joins it; heavy alcohol use; systemic disease; trauma; and, in children, mumps. Acute pancreatitis may be a single event; it may be recurrent; or it may progress to chronic pancreatitis and/or pancreatic failure.

<span class="mw-page-title-main">Chronic pancreatitis</span> Medical condition

Chronic pancreatitis is a long-standing inflammation of the pancreas that alters the organ's normal structure and functions. It can present as episodes of acute inflammation in a previously injured pancreas, or as chronic damage with persistent pain or malabsorption. It is a disease process characterized by irreversible damage to the pancreas as distinct from reversible changes in acute pancreatitis. Tobacco smoke and alcohol misuse are two of the most frequently implicated causes, and the two risk factors are thought to have a synergistic effect with regards to the development of chronic pancreatitis. Chronic pancreatitis is a risk factor for the development of pancreatic cancer.

<span class="mw-page-title-main">Pancreaticoduodenectomy</span> Major surgical procedure involving the pancreas, duodenum, and other organs

A pancreaticoduodenectomy, also known as a Whipple procedure, is a major surgical operation most often performed to remove cancerous tumours from the head of the pancreas. It is also used for the treatment of pancreatic or duodenal trauma, or chronic pancreatitis. Due to the shared blood supply of organs in the proximal gastrointestinal system, surgical removal of the head of the pancreas also necessitates removal of the duodenum, proximal jejunum, gallbladder, and, occasionally, part of the stomach.

<span class="mw-page-title-main">Pancreatectomy</span> Surgical removal of the pancreas

In medicine, a pancreatectomy is the surgical removal of all or part of the pancreas. Several types of pancreatectomy exist, including pancreaticoduodenectomy, distal pancreatectomy, segmental pancreatectomy, and total pancreatectomy. In total pancreatectomy, the gallbladder, distal stomach, a portion of the small intestine, associated lymph nodes and in certain cases the spleen are removed in addition to the entire pancreas. In recent years, the TP-IAT has also gained respectable traction within the medical community. These procedures are used in the management of several conditions involving the pancreas, such as benign pancreatic tumors, pancreatic cancer, and pancreatitis.

<span class="mw-page-title-main">Pancreatic duct</span> Duct associated with the human pancreas

The pancreatic duct or duct of Wirsung is a duct joining the pancreas to the common bile duct. This supplies it with pancreatic juice from the exocrine pancreas, which aids in digestion.

<span class="mw-page-title-main">Pancreatic fistula</span> Medical condition

A pancreatic fistula is an abnormal communication between the pancreas and other organs due to leakage of pancreatic secretions from damaged pancreatic ducts. An external pancreatic fistula is one that communicates with the skin, and is also known as a pancreaticocutaneous fistula, whereas an internal pancreatic fistula communicates with other internal organs or spaces. Pancreatic fistulas can be caused by pancreatic disease, trauma, or surgery.

<span class="mw-page-title-main">Pancreas divisum</span> Congenital disorder of digestive system

Pancreas divisum is a congenital anomaly in the anatomy of the ducts of the pancreas in which a single pancreatic duct is not formed, but rather remains as two distinct dorsal and ventral ducts. Most individuals with pancreas divisum remain without symptoms or complications. A minority of people with pancreatic divisum may develop episodes of abdominal pain, nausea or vomiting due to acute or chronic pancreatitis. The presence of pancreas divisum is usually identified with cross sectional diagnostic imaging, such as endoscopic retrograde cholangiopancreatography (ERCP) or magnetic resonance cholangiopancreatography (MRCP). In some cases, it may be detected intraoperatively. If no symptoms or complications are present, then treatment is not necessary. However, if there is recurrent pancreatitis, then a sphincterotomy of the minor papilla may be indicated.

<span class="mw-page-title-main">Annular pancreas</span> Medical condition

Annular pancreas is a rare condition in which the second part of the duodenum is surrounded by a ring of pancreatic tissue continuous with the head of the pancreas. This portion of the pancreas can constrict the duodenum and block or impair the flow of food to the rest of the intestines. It is estimated to occur in 1 out of 12,000 to 15,000 newborns. The ambiguity arises from the fact that not all cases are symptomatic.

<span class="mw-page-title-main">Exocrine pancreatic insufficiency</span> Human disease

Exocrine pancreatic insufficiency (EPI) is the inability to properly digest food due to a lack or reduction of digestive enzymes made by the pancreas. EPI can occur in humans and is prevalent in many conditions such as cystic fibrosis, Shwachman–Diamond syndrome, different types of pancreatitis, multiple types of diabetes mellitus, advanced renal disease, older adults, celiac disease, IBS-D, IBD, HIV, alcohol-related liver disease, Sjogren syndrome, tobacco use, and use of somatostatin analogues.

Pancreatic diseases are diseases that affect the pancreas, an organ in most vertebrates and in humans and other mammals located in the abdomen. The pancreas plays a role in the digestive and endocrine system, producing enzymes which aid the digestion process and the hormone insulin, which regulates blood sugar levels. The most common pancreatic disease is pancreatitis, an inflammation of the pancreas which could come in acute or chronic form. Other pancreatic diseases include diabetes mellitus, exocrine pancreatic insufficiency, cystic fibrosis, pseudocysts, cysts, congenital malformations, tumors including pancreatic cancer, and hemosuccus pancreaticus.

<span class="mw-page-title-main">Hemosuccus pancreaticus</span> Medical condition

Hemosuccus pancreaticus is a rare cause of hemorrhage in the gastrointestinal tract. It is caused by a bleeding source in the pancreas, pancreatic duct, or structures adjacent to the pancreas, such as the splenic artery, that bleed into the pancreatic duct, which is connected with the bowel at the duodenum, the first part of the small intestine. Patients with hemosuccus may develop symptoms of gastrointestinal hemorrhage, such as blood in the stools, maroon stools, or melena, which is a dark, tarry stool caused by digestion of red blood cells. They may also develop abdominal pain. It is associated with pancreatitis, pancreatic cancer and aneurysms of the splenic artery. Hemosuccus may be identified with endoscopy (esophagogastroduodenoscopy), where fresh blood may be seen from the pancreatic duct. Alternatively, angiography may be used to inject the celiac axis to determine the blood vessel that is bleeding. This may also be used to treat hemosuccus, as embolization of the end vessel may terminate the hemorrhage. However, a distal pancreatectomy—surgery to remove of the tail of the pancreas—may be required to stop the hemorrhage.

<span class="mw-page-title-main">PDX1</span> A protein involved in the pancreas and duodenum differentiation

PDX1, also known as insulin promoter factor 1, is a transcription factor in the ParaHox gene cluster. In vertebrates, Pdx1 is necessary for pancreatic development, including β-cell maturation, and duodenal differentiation. In humans this protein is encoded by the PDX1 gene, which was formerly known as IPF1. The gene was originally identified in the clawed frog Xenopus laevis and is present widely across the evolutionary diversity of bilaterian animals, although it has been lost in evolution in arthropods and nematodes. Despite the gene name being Pdx1, there is no Pdx2 gene in most animals; single-copy Pdx1 orthologs have been identified in all mammals. Coelacanth and cartilaginous fish are, so far, the only vertebrates shown to have two Pdx genes, Pdx1 and Pdx2.

<span class="mw-page-title-main">Renal cysts and diabetes syndrome</span> Medical condition

Renal cysts and diabetes syndrome (RCAD), also known as MODY 5 or HNF1B-MODY, is a form of maturity onset diabetes of the young.

<span class="mw-page-title-main">Canine pancreatitis</span>

Canine pancreatitis is inflammation of the pancreas that can occur in two very different forms. Acute pancreatitis is sudden, while chronic pancreatitis is characterized by recurring or persistent form of pancreatic inflammation. Cases of both can be considered mild or severe.

Pancreaticobiliary maljunction(PBM) is a congenital malformation where the pancreatic and bile ducts meet outside of the duodenum. There are two varieties of PBM: one with biliary dilatation and the other without. When an abnormally long common channel is visible on direct cholangiography, such as endoscopic retrograde cholangiopancreatography or magnetic resonance cholangiopancreatography, PBM is diagnosed.

<span class="mw-page-title-main">Pancreatic progenitor cell</span>

Pancreatic progenitor cells are multipotent stem cells originating from the developing fore-gut endoderm which have the ability to differentiate into the lineage specific progenitors responsible for the developing pancreas.

Type 3c diabetes is diabetes that comes secondary to pancreatic diseases, involving the exocrine and digestive functions of the pancreas. It also occurs following surgical removal of the pancreas.

References

  1. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 Sakpal, Sujit Vijay; Sexcius, Lucretia; Babel, Nitin; Chamberlain, Ronald Scott (May 2009). "Agenesis of the Dorsal Pancreas and Its Association With Pancreatic Tumors". Pancreas. 38 (4): 367–373. doi:10.1097/MPA.0b013e318196c401. ISSN   0885-3177. PMID   19390403.
  2. 1 2 3 4 5 6 A.-Cienfuegos, Javier; Rotellar, Fernando; Salguero, Joseba; Benito, Alberto; Solórzano, José Luis; Sangro, Bruno (2016). "Agenesis of the dorsal pancreas: systematic review of a clinical challenge". Revista Española de Enfermedades Digestivas. 108 (8): 479–484. doi: 10.17235/reed.2016.4474/2016 . ISSN   1130-0108. PMID   27468966.
  3. 1 2 3 4 5 Zhong, Jin Wei; Yu, Ling Min; Ying, Qing Ji; Peng, Wen Wen; Xu, Chang Zhao; Cai, Zhen Zhai; Xue, Zhan Xiong; Zhou, Yu Hui (May 2020). "Performance of endoscopic ultrasound for diagnosis of agenesis of the dorsal pancreas: a case report". Journal of International Medical Research. 48 (5): 030006051988414. doi:10.1177/0300060519884148. ISSN   0300-0605. PMC   7265568 . PMID   31680602.
  4. 1 2 3 4 5 6 Mei, Wentong; Cao, Feng; Li, Fei (December 2020). "Two cases of agenesis of the dorsal pancreas and a review of the literature". BMC Gastroenterology. 20 (1): 94. doi: 10.1186/s12876-020-01245-8 . ISSN   1471-230X. PMC   7137410 . PMID   32252649.
  5. 1 2 Edlund, H. (December 1998). "Transcribing pancreas". Diabetes. 47 (12): 1817–1823. doi:10.2337/diabetes.47.12.1817. ISSN   0012-1797. PMID   9836511.
  6. 1 2 Hebrok, Matthias; Kim, Seung K.; St-Jacques, Benoit; McMahon, Andrew P.; Melton, Douglas A. (2000-11-15). "Regulation of pancreas development by hedgehog signaling". Development. 127 (22): 4905–4913. doi:10.1242/dev.127.22.4905. ISSN   0950-1991. PMID   11044404.
  7. 1 2 3 4 5 6 7 8 9 10 11 Schnedl, Wolfgang J.; Piswanger-Soelkner, Claudia; Wallner, Sandra J.; Reittner, Pia; Krause, Robert; Lipp, Rainer W.; Hohmeier, Hans E. (March 2009). "Agenesis of the Dorsal Pancreas and Associated Diseases". Digestive Diseases and Sciences. 54 (3): 481–487. doi:10.1007/s10620-008-0370-3. ISSN   0163-2116. PMID   18618254.
  8. 1 2 3 Thakur, Shruti; Jhobta, Anupam; Sharma, Dinesh; Thakur, Charu S (May 2014). "MR in complete dorsal pancreatic agenesis: Case report and review of literature". Indian Journal of Radiology and Imaging. 24 (2): 156–159. doi: 10.4103/0971-3026.134401 . ISSN   0971-3026. PMC   4094968 . PMID   25024525.
  9. 1 2 3 Ashraf, Ambika; Abdullatif, Hussein; Hardin, William; Moates, J Michael (December 2005). "Unusual case of neonatal diabetes mellitus due to congenital pancreas agenesis". Pediatric Diabetes. 6 (4): 239–243. doi:10.1111/j.1399-543X.2005.00114.x. ISSN   1399-543X. PMID   16390394.
  10. ↑ Wildling, Reinhard; Schnedl, Wolfgang J.; Reisinger, Emil C.; Schreiber, Florian; Lipp, Rainer W.; Lederer, Adolf; Krejs, Guenter J. (April 1993). "Agenesis of the dorsal pancreas in a woman with diabetes mellitus and in both of her sons". Gastroenterology. 104 (4): 1182–1186. doi:10.1016/0016-5085(93)90290-S. PMID   8462806.
  11. ↑ Caetano, L.A.; Santana, L.S.; Costa-Riquetto, A.D.; Lerario, A.M.; Nery, M.; Nogueira, G.F.; Ortega, C.D.; Rocha, M.S.; Jorge, A.A.L.; Teles, M.G. (February 2018). "PDX1 - MODY and dorsal pancreatic agenesis: New phenotype of a rare disease". Clinical Genetics. 93 (2): 382–386. doi:10.1111/cge.13044. hdl: 2027.42/142027 . ISSN   0009-9163. PMID   28436541.
  12. ↑ Esni, Farzad; Johansson, Bengt R.; Radice, Glenn L.; Semb, Henrik (October 2001). "Dorsal Pancreas Agenesis in N-Cadherin- Deficient Mice". Developmental Biology. 238 (1): 202–212. doi:10.1006/dbio.2001.0405. ISSN   0012-1606. PMID   11784004.
  13. ↑ Martín, Mercè; Gallego-Llamas, Jabier; Ribes, Vanessa; Kedinger, Michèle; Niederreither, Karen; Chambon, Pierre; Dollé, Pascal; Gradwohl, Gérard (August 2005). "Dorsal pancreas agenesis in retinoic acid-deficient Raldh2 mutant mice". Developmental Biology. 284 (2): 399–411. doi:10.1016/j.ydbio.2005.05.035. PMID   16026781.
  14. 1 2 Saladin, Kenneth S.; Gan, Christina A.; Cushman, Heather N. (2021). Anatomy & physiology: the unity of form and function (Ninth ed.). New York, NY: McGraw-Hill Education. ISBN   978-1-260-57129-5. OCLC   1183718219.
  15. ↑ Henry, Brandon Michael; Skinningsrud, Bendik; Saganiak, Karolina; Pękala, Przemysław A.; Walocha, Jerzy A.; Tomaszewski, Krzysztof A. (January 2019). "Development of the human pancreas and its vasculature — An integrated review covering anatomical, embryological, histological, and molecular aspects". Annals of Anatomy - Anatomischer Anzeiger. 221: 115–124. doi:10.1016/j.aanat.2018.09.008. PMID   30300687.
  16. ↑ Dhakal, Binaya; Pant, Sujit; Choudhary, Saroj; Basnet, Bina; Neupane, Shanta (June 2023). "Dorsal pancreatic agenesis: a case report". Annals of Medicine & Surgery. 85 (6): 2949–2952. doi:10.1097/MS9.0000000000000136. ISSN   2049-0801. PMC   10289771 . PMID   37363558.
  17. ↑ "Pancreatic Enzymes Oral: Uses, Side Effects, Interactions, Pictures, Warnings & Dosing - WebMD". www.webmd.com. Retrieved 2024-03-25.
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